The Status Syndrome

Let me translate “where you stand in the social hierarchy.” You are not poor. You are employed. Your children are well fed. You live in a decent house or apartment. You turn on the faucet and drink the water in the secure knowledge that it is clean. The food you buy is similarly not contaminated. Most people you come across in your daily routine also meet this description. But, among these people, none of whom is destitute or even poor, you acknowledge that some are higher than you in the social hierarchy: they may have more money, bigger houses, a more prestigious job, more status in the eyes of others, or simply a higher-class way of speaking. You also note that there are other people lower than you on these criteria, not just the very poor or the homeless, but people whose standing is merely lower than yours, to a varying extent. The remarkable finding is that among all of these people, the higher the status in the pecking order, the healthier they are likely to be. In other words, health follows a social gradient. I call this the status syndrome. (Location 32)

How do these experiences translate into illness? Quite simply, the key lies in that most important organ, the brain. The psychological experience of inequality has profound effects on body systems. The evidence we shall examine suggests that this may be a major factor in generating the status syndrome. (Location 130)

I shall also consider, only to discard, the proposition that the causal direction runs the other way: that it might be the glow of good health that leads to some becoming princes, and that those racked by illness end up paupers. (Location 144)

In other words, it is your health that determines where you will end up, not where you end up that determines your health. (Location 145)

What is the difference between her poverty and his? Poverty is more than lack of money. He and his educated bohemian friends—poet, artist, musician, and philosopher—are in control. They live the way they do by choice, in a way that the unfortunate embroiderer does not. (Location 244)

The men at the bottom of the office hierarchy have, at ages forty to sixty-four, four times the risk of death of the administrators at the top of the hierarchy. (Location 690)

Second, we studied the medical care issue directly in relation to heart disease. We showed that people in the lower ranks of the civil service were more likely to be investigated and treated for coronary heart disease than people in the higher ranks. (Location 750)

The problem with this approach is that the evidence is against it, whatever one’s view of determinism and free will. These differences in lifestyle provide only a modest explanation of the social gradient in health. This is shown in Figure 2.2. The mathematics behind this figure is not very complicated, the logic even simpler. If low-grade men died earlier from heart disease because they had higher levels of risk factors—smoking, blood pressure, plasma cholesterol, short height, and blood sugar—then “adjusting” for these would make the risk in the “other” grade not 1.8 times that of the top grade, but the same: the relative mortality would be 1. But it is not 1. It is just under 1.5. (Location 785)

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“Adjusting” for these risk factors explains less than a third of the social gradient in mortality from heart disease. (Location 790)

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To be more precise, men in the top grade are, on average, 5 cm (2 inches) taller than men in the bottom grade. The differences are a bit smaller for women but, as with men, the high grades are taller than the lower. (Location 872)

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For example, the United States, which has the highest gross domestic product (GDP) in purchasing power (except for Luxembourg), ranks twenty-sixth in life expectancy. The four-year difference in life expectancy between first-place Japan and the United States would be as if the Japanese all won Oscars and the Americans were all also-rans. Israel, Greece, Malta, and New Zealand—all countries with GDP under $20,000 per person—have higher life expectancy than the United States. Among these developed countries, there is simply little relation between average income and health. Greece, with a GDP of a little over $17,000 per person, has longer life expectancy than the United States with twice the national income. (Location 1174)

Once a country has solved its basic material conditions for good health, more money does not buy better health. When comparing whole countries, there is no gradient in the relation between income and health. (Location 1179)

For further dramatic evidence that income itself is not the issue, look beyond the figures in Table 3.1 for the United States, at those for African-Americans. One estimate puts the average U.S. black income at $26,000 per person.13 They are, by world standards, rich. Yet, life expectancy for U.S. blacks is 71.4, way below that of poor countries such as Costa Rica (77.9) or Cuba (76.5). (Location 1189)

The fifteen-year-old white teenage has a 77 percent chance of still being alive at age sixty-five. The black teenager has a 37 percent chance.15 Two out of three black fifteen-year-olds on the streets of New York will not see their sixty-fifth birthday. Three out of four whites in Michigan will. (Location 1199)

For Patty, the issue is being able to participate fully in society, which includes giving her children what the other kids have. She smokes, does no exercise, and is overweight—all bad for her health. But to focus on these, and blame her for her poor lifestyle, is to focus on symptoms rather than the cause. If smoking, being overweight, and lack of exercise are causes of ill health, then we have to look at the causes of the causes. (Location 1236)

different “space” is that of capabilities. Sen argues that more crucial than what we have, in terms of income, is what we are capable of doing, physically, psychologically, and socially. Income should not be thought of as an end in itself. (Location 1274)

It is a means to some other end. Most would accept that that end has something to do with quality of life. Sen would argue that the end is capabilities, or freedom. Income is only one means to that end. (Location 1276)

To repeat: if you have little of it, more money would benefit health, but if you have more of it, then it is how much you have compared to other people in your society that is more important for health. (Location 1313)

There are credible pathways by which lacking the necessaries, in the Adam Smith sense, can lead to ill health. Lack of social participation and inadequate control over your life, in the sense of not being able to lead the life you want to lead, will lead to chronic stress, which in turn increases risk of a number of diseases, heart disease among them. (Location 1346)

the higher the social position, the greater the level of happiness. (Location 1516)

We have, then, an apparent contradiction: two very different results, depending on how we ask the question. As a country gets richer over time, the rise in average income does not go along with an increase in happiness. Comparing individuals at one point in time, within a country, the relation of income to happiness is quite clear. (Location 1519)

The importance of relative position fits with everyday experience. We are all concerned with where we stand. We may choose the criterion by which we compare ourselves to others, but that does not mean we are unconcerned. Like most academics, my self-esteem or my status in the eyes of others has little to do with the size of my car, for example. (I see my fifteen-year-old, nontrendy bicycle as relative insurance against theft.) This does not mean academics are insensitive to where we stand in the hierarchy, however. Far from it. We are being judged all the time. (Location 1530)

Veblen argued that in modern urban society—his book was published in 1899—where people came and went and did not know one another well, wealth was advertised by conspicuous consumption. In a small English village, for example, everyone knew who had the wealth and who did not. When this local knowledge was not available, it was important for people not just to have the wealth but to flaunt it. Veblen argued that consumption for show, to achieve status and recognition, was important in addition to whatever comforts were afforded by the goods thus acquired. (Location 1539)

Never lose your cool, even when you are fighting. All they have is this cool. Cool is like building a fortress around yourself.” (Location 1794)

Or drop dead. On this day, Saturday, June 22, forty-one men in Holland dropped dead from a heart attack or stroke.2 Of course, such deaths occur every day in Holland. Why attribute these deaths to a soccer match? On the average day the week before, twenty-seven men dropped dead from a heart attack or stroke. On this particular Saturday, the death rate went up 50 percent in men, although not in women. Applying the usual statistical tests, it was possible to draw a connection that was unlikely to be due to the play of chance. (Location 1881)

Americans are divided in their sports affiliations along class lines—the smaller the ball, the higher the social rank: golf, tennis, baseball, football, and basketball. Sport also divides us along lines of sex. (Location 1889)

Sustained, chronic, and long-term stress is linked to low control over life circumstances. (Location 1927)

To see how low control is related to social position, consider the following situation: a threatened factory closure that affects people quite differently depending on their place in the social hierarchy. An uncontrollable stress for the factory worker is a challenge for the CEO. (Location 1927)

The point here is that Rick has the resources to take control of the situation rather than have events control him. These resources may be knowledge—how to operate the system; financial—he can bear the cost of the solution without pain; psychological—he has the confidence, developed by long experience, to know that he can do what is required and people respond to that confidence, whether it is the clerk in the insurer’s office, the repairers, or his employees. These are all resources that to a greater or lesser extent Maria and Billy lack. (Location 1982)

Her husband Paul’s reaction to his job loss is to become morose and depressed and to drink heavily. He has lost work, lost money, lost status. The last feature of these stories that has relevance to the degree of stress is the presence of an outlet. (Location 2002)

There is a large body of literature supporting the importance of these five characteristics—control, predictability, degree of support, threat to status, and presence of outlets—that modulate the impact of a psychologically threatening stimulus.6 All five of them are likely to be linked to position in the social hierarchy. (Location 2006)

But animals are not all equally affected. These animals form themselves into hierarchies. The higher the rank of the animal, the less likely is it to develop atherosclerosis, despite, as I have argued, the lack of the usual lifestyle that constitutes risk factors for disease in humans: smoking or variation in diet. (Location 2095)

We have, therefore, to go beyond the notion of “stress” at work as meaning “having a lot to do.” We need to put some precision into the concept of the psychosocial work environment. This has been done in two ways. First, the main issue for a stressful workplace is not simply the level of psychological demands, but the balance between demands and control.17 Second, work will be stressful if there is lack of balance between effort and rewards. (Location 2193)

for the first seven decades of the twentieth century the legal and medical professions grew roughly in tandem, but after 1970 the legal profession grew twice as fast. In 1970 there were 3 percent fewer lawyers than doctors, but by 1995 there were 34 percent more lawyers than doctors. (Location 2593)

That at least is the historical account that Tolstoy quotes. He dismisses it as far too simplistic. Were Napoleon’s orders the cause of the carnage at Borodino? This is Tolstoy’s view: The soldiers of the French army went to kill the Russian soldiers at Borodino not because of Napoleon’s orders, but by their own volition. At the sight of an army barring their road to Moscow, the whole army—the French, Italians, Germans, Poles—hungry, ragged, and exhausted by the campaign, felt that the wine was drawn and must be drunk. Had Napoleon then forbidden them to fight the Russians, they would have killed him and would have proceeded to fight the Russians because it was inevitable.10 There must, in other words, be a richer, more complex view of causation. Suppose that Napoleon’s decision to fight that particular battle had some effect in determining that the battle was fought at Borodino, and not elsewhere, on August 26 and not on another day. It was, in a sense, only the proximate cause of death in battle of so many men. A whole set of causal processes determined that the battle would be fought somewhere. We need to think about illness in the same way. When a person dies, a death certificate is completed that lists cause of death. In the space for “cause,” it does not ask for a judgment call on the failure of memory of Napoleon’s valet. It asks for the illness to which the deceased succumbed. If someone died of cancer, the appropriate entry under cause of death might be lung cancer (carcinoma of the trachea, bronchus, or lung), not smoking. Statistics on “cause” of death, therefore, tell us about frequency of different fatal illnesses, not what caused them. (Location 2641)

He contrasts three models of capitalism: Anglo-Saxon (Anglo-American), Continental European, and Japanese. In characterizing relations between management and labor he says: There is first the Anglo-Saxon pattern where the adversarial relation is for real: the knives are out. The second is the continental European pattern; the knives are kept in their sheaths while people play poker according to rules which everybody has a hand in working out. The third is the Japanese pattern: the rules are well established and not much changing, the knives are locked away in the family cupboard and it is only when the senior members of the family flagrantly break the rules that people lower down the hierarchy start wondering where they put those knives. (Location 3176)